Carlos Avila, Catherine Connor, Tesfaye Dereje, Sharon Nakhimovsky and Wendy Wong

1. Universal coverage of essential health services in sub Saharan Africa: projections of domestic resources Carlos Avila, Catherine Connor, Tesfaye Dereje, Sharon Nakhimovsky and Wendy Wong Health Finance and Governance Project 17 July 2013

2. Outline • Background • Questions addressed • Methods • Results • Limitations • Summary & conclusions • Implications for donors

3. Background • High level advocacy to mobilize more funding for health dominated the first decade of the new millennium, from • the Commission on Macroeconomics and Health in 2001 to the • Taskforce on Innovative International Financing for Health Systems in 2009 and • the UN Millennium Project (MDGs) • Abuja commitment (15% of budget on health)  • During the same decade, some African countries experienced unprecedented economic growth, and improvements in governance, trade, health status and life expectancy.

4. Africa Rising

5. Questions addressed

6. Questions addressed • Can the region’s continued economic growth lift African countries’ domestic health spending to the target of $60 per person per year by 2020? • If in addition to economic growth, African governments fulfilled the Abuja commitment, which countries would reach the spending target? • What is the projected impact on household out-of-pocket expenditures on health? • What financing gap would remain in 2020?

7. methods

8. Methods 1: Sources and models • Established a baseline level of domestic health spending for 43 sub-Saharan African countries using data from the WHO Global Health Observatory. • Estimated two policy-relevant models to project domestic health spending to 2020: • (1) domestic health spending increases with economic growth and • (2) in addition to economic growth, government expenditures allocated to health increase until they reach the Abuja commitment.

9. Methods 2: The target is a set of cost-effective health services for $60/capita • “…extending the coverage of health services and a small number of critical interventions to the world's poor could save millions of lives, reduce poverty, spur economic development, and promote global security” --Commission on Macroeconomics and Health, 2001 • Taskforce on Innovative International Financing for Health Systems, 2009 • Public investments in health and the MDGs; UN’s Millennium Project, 2010

10. Methods 3: Domestic health spending per capita increases with GDP (Baseline-2010) $54 $148 $403 $1,097 $2,981 $8,103 GDP Per Capita (Log Scale)

11. Summary of assumptions used to project total domestic health spending • [1] (Xu, Saksena, & Holly, 2011) • [2] (Govindaraj, Chellaraj, & Murray, 1997)

12. Results

13. Observed health spending by source in 41 SSA countries, 2000-2010

14. Growth in total domestic health spending assuming economic growth: country averages for the lower three quartiles of GDP per capita

15. Per capita domestic health spending in 2020 under economic growth only and economic growth with the Abuja commitment

16. Growth in domestic health spending in 43 countries, under economic growth and Abuja commitment, by source, 2000-2020 Political commitment

17. Countries reaching the $60 per capita spending target through health financing from domestic sources

18. OOP spending as a percent of THE by country income quartile assuming economic growth and Abuja commitment is met

19. Funding gap in 2020 • To reach the $60 per capita target with economic growth alone, 21 countries would face a collective funding gap of $14.5 billion in 2020. • 7 countries account for 78% of the gap • DRC, Ethiopia, Uganda and Madagascar will have the highest projected gaps in 2020 • The collective funding gap would drop to $8.2 billion in 2020, IF countries met the Abuja commitment.

20. Funding gap under the two projections for total domestic health financing growth by 2020 (million US$)

21. Limitations & Caveats

22. Limitations 1 • Health spending on average has tended to increase with economic growth; however, individual country income elasticity varies. • The WHO Global Health Observatory data on government health expenditures includes on-budget donor funding. • We used detailed NHA data from a 10 countries to adjust the estimates of government health expenditure and non-OOP private spending to remove donor funding. • Limitations of the HLTF analysis to estimate the cost of a package of essential services are presented in their publications.

23. Limitations 2 • The assumption that governments will choose to fulfill the Abuja commitment is very optimistic given that very few countries have met the Abuja commitment since it was declared in 2001. • THE per capita masks significant inequities in almost all the countries.

24. Caveats • The assumption that governments spending $60 per capita on health will ensure universal access to essential services is far from assured

25. Summary, conclusions, AND IMPLICATIONS FOR DONORS

26. Summary Summary

27. Conclusions • Rising domestic resources alone are not enough to ensure access to essential health services in all countries. • Leadership and other governance actions are required. • Countries and their partners need to emphasize key health financing priorities in addition to resource mobilization: • efficient allocation to essential health services and to underserved populations; • improved risk pooling and • strategic purchasing for quality and efficiency.

28. Implications for donors High dependency Low dependency Expected changes in external assistance as percentage of THE, under economic growth and Abuja commitment, 2010 and 2020

29. Implications for donors • How to encourage countries to meet the Abuja commitment? • How to enable countries to make the most of their expanding funding envelope? • To allocate funds to essential health services • To target underserved populations • To expand risk pooling (rich subsidize the poor; healthy subsidize the sick) • To use purchasing power to improve quality and efficiency

30. Thank you www.hfgproject.org